Vasectomie.net

Sexual Function/InfertilityMinimizing Pain During Vasectomy: The Mini-NeedleAnesthetic Technique
Grace Shih, Merlin Njoya, Marylène Lessard and Michel Labrecque*
From the Department of Family and Community Medicine, University of California-San Francisco (GS), San Francisco, California, andResearch Centre of the Centre Hospitalier Universitaire de Québec (MN, ML) and Department of Family and Emergency Medicine, LavalUniversity, Québec City (ML), Québec, CanadaPurpose: We describe pain scores for a modified anesthesia technique for no-Abbreviations
scalpel vasectomy using a 1-inch 30 gauge mini-needle.and AcronymsMaterials and Methods: A prospective study was performed in 277 patients who
received anesthesia using a 3 cc syringe filled with approximately 2 cc 2%
lidocaine without epinephrine and a 1-inch 30 gauge needle. Local anesthesia
was given directly to the vas at the expected surgical site on each side.Results: Mean Ϯ SD pain intensity score on the 10 cm visual analog scale was1.5 Ϯ 1.6 (95% CI 1.3–1.7) during the anesthesia and 0.6 Ϯ 1.0 (95% CI 0.5– 0.7)
during the procedure. Patients experienced less pain during anesthesia and the
procedure than they expected before vasectomy (average 3.1 Ϯ 1.8, 95% CI2.8 –3.3).
Submitted for publication September 6, 2009.Conclusions: The mini-needle technique provides excellent anesthesia for no-
Study received hospital medical director ap-
scalpel vasectomy. It compares favorably to the standard vasal block and other
Supplementary material for this article can be
anesthetic alternatives with the additional benefit of minimal equipment and less
* Correspondence: Hôpital Saint-François d’Assise
D6-728, 10 rue de l’Espinay, Québec, Canada, G1L 3L5
Key Words: testis; vasectomy; anesthesia, local; pain; pain measurement
(telephone: 418-525-4444 ext. 52419; FAX: 418-525-4194; e-mail:
adjunct to infiltration anesthesia, buffer-
2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
1-inch needle. The mini-needle technique should
Data Collection
be an acceptable alternative to the standard vasal
Patients were asked to complete a preoperative question-
block. It uses commonly available materials and
naire in the waiting room while waiting for surgery. The
requires a smaller quantity of anesthesia to pro-
questionnaire included a 10 cm VAS on expected painintensity (score 0 —no pain to 10 —worst possible pain)
and a 5-item VDS of overall pain expected (score 0 —no,1—mild, 2— discomforting, 3— distressing, 4 —intenseand 5— excruciating pain) during vasectomy. The ques-
MATERIALS AND METHODS
tionnaire was given to a nurse after completion.
Immediately after vasectomy patients were asked to
Participants
complete a postoperative questionnaire. They had no ac-
Patients were recruited between January and February
cess to the preoperative questionnaire. The postoperative
2007, and May and June 2009 at 2 primary care private
questionnaire included assessment of actual pain related
clinics and 1 family planning clinic in a tertiary care
to anesthesia and actual pain related to vasectomy. Pain
teaching hospital. Patients scheduled to undergo the first
assessment of anesthesia and vasectomy included 3 ques-
vasectomy entered the study after verbally agreeing to
tions, including a 10 cm VAS of pain intensity, a 10 cm
answer a preoperative and postoperative pain question-
VAS of unpleasantness and a 5 item VDS of pain. VDS
naire. Patients were recruited in consecutive fashion and
descriptors were identical to those described. Preoperative
none refused study participation. The study was reviewed
and postoperative questionnaires were matched based on
and accepted as an evaluation of the quality of care by the
AnalysisClinical Procedures
The same ruler was used to measure VAS results in all
The mini-needle technique was introduced in late 2006 at
patients. All measurements and data entry were done by
all 3 participating clinics. This technique replaced the
an independent research assistant. The mean is with the
vasal block that had been in use since NSV was
SD and 95% CI. The Student t test was used to evaluate
differences between surgical sites (private clinics vs hos-
To perform the mini-needle technique a 3 cc syringe is
pital clinic) and years (2007 vs 2009). The Pearson corre-
filled with approximately 2 cc 2% lidocaine without epi-
lation coefficient was calculated to evaluate the correla-
nephrine. A 1-inch 30 gauge needle is attached before
tion between scores reported on different pain scales.
injection. With the surgeon on the right side of the patientthe left vas deferens is secured using the traditional 3finger technique of NSV. As in the standard vas block
the needle entry site is over the vas deferens,
A total of 277 patients were recruited to participate
midway between the top of the testes and the base of the
in the study, including 84 in 2007 and 193 in 2009.
penis over the median raphe. Using the needle tip a su-
Average patient age was 38 Ϯ 6 years (range 26 to
perficial skin wheal is raised with approximately 0.5 cc.The surgeon then redirects the needle directly to the vas
58). Of the 277 patients 50 (18%) were recruited at
at the expected surgical site and infiltrates 0.5 to 0.75 cc
the tertiary care hospital family planning clinic and
anesthesia as close as possible to and even into the vas
227 (82%) were recruited at private clinics. Three
deferens. The procedure is repeated for the right vas de-
patients left at least 1 item of the questionnaire
ferens except the superficial skin wheal is not repeated
unanswered. Six of the total of 2,216 items (0.3%)
since the needle reenters through the previously used site.
were unanswered, including 1 on VAS expected
Vasectomy is started immediately on the left side after
pain, 2 on VDS expected pain, 1 on VAS vasectomy
finishing anesthesia on the right side.
pain intensity, 1 on VAS vasectomy unpleasantness
In all cases the NSV technique was used to secure and
and 1 on VDS vasectomy pain. These missing items
extract the vas from the Vasal occlusion was
achieved using thermal cautery of the prostatic end of the
The lists pain outcome results. An average
vas, fascial interposition with a medium Hemoclip® over
of almost no pain was perceived during vasectomy,
the prostatic end and excision of approximately 5 mm of
mild pain was perceived during anesthesia and dis-
the testicular end, which remained open In 17
comforting pain was expected before surgery. The 10
consecutive patients average total operative time from
cm VAS and the 5-item VDS results for expected
anesthetic injection to skin dressing was 5.0 Ϯ 1.1 min-
pain correlated highly (r ϭ 0.72, p Ͻ0.0001), as did
the 3 scales to measure pain during anesthesia (r ϭ
A verbal announcement was made at the beginning and
end of anesthesia, and at the start of vasectomy to delin-
0.71 to 0.82, each p Ͻ0.0001) and during vasectomy
eate these time points for the patient. Anesthesia and
(r ϭ 0.67 to 0.91, each p Ͻ0.0001). Pain scores dur-
vasectomy were done by a single surgeon (ML), who per-
ing anesthesia and during vasectomy correlated
forms more than 1,000 cases per year. No mention or
moderately (r ϭ 0.44 to 0.55, each p Ͻ0.0001). How-
discussion about pain was done during or after the proce-
ever, although they were statistically significant,
correlations of expected pain scores with pain scores
Pain outcome with mini needle anesthesia during vasectomy
lower. Using the mini-needle technique the average
VAS pain score for vasectomy was 0.6. In studies
using a traditional vasal block that measured pain
on a 10 cm VAS scale the mean pain score was 1.9 to
3.3. There are limitations to these comparisons.
These studies done at various sites and in various
clinical contexts used different anesthetic prepara-
tions and needle gauges, and surgeons with varying
skill levels. In our study all procedures were done by
1 experienced surgeon, which may have contributed
to our low pain scores. Also, given the different back-
grounds of the patients in these studies, cultural or
other differences in pain perception may not makethe VAS scale universally comparable. Due to theseveral variables that may influence pain perceived
during anesthesia or during vasectomy were low
and reported by patients comparisons across studies
must be made while considering these limitations.
We compared pain intensity, unpleasantness and
Our technique also compares favorably with vari-
overall pain scores by surgical site and by year. There
ations of the traditional vasal block. Recently SCB
were no statistically significant differences among the
was suggested as an alternative vasectomy anesthe-
sites in any pain measure. When analyzing pain scores
A 30 gauge 0.5-inch needle was used for SCB,
by year, we found a statistical difference only in ex-
which is similar to our mini-needle but shorter (0.5
pected pain scores. Patients in 2007 had a higher av-
vs 1 inch). SCB uses an equal mixture of 1% lido-
erage expected VAS score than those in 2009 (3.4 Ϯ 1.8
caine with epinephrine and 0.5% bupivacaine. Ap-
vs 2.9 Ϯ 1.8, p ϭ 0.02). There were no statistically
proximately 4 cc anesthesia were infiltrated in each
significant differences between the 2 periods in all
spermatic cord. An additional 1 to 2 cc were used for
other pain measures. No adverse events were noted
local anesthesia on the scrotal skin for a total of 10
except occasional perivasal ecchymosis, which did not
cc compared to 2 cc for our technique. The average
pain scores of 1.7 and 0.6 on a 10 cm VAS for SCBwith local anesthesia during anesthesia and vasec-tomy, respectively, were similar to those of our tech-
DISCUSSION
Given the efficacy, cost-effectiveness and safety of
Other variations of the traditional block include
vasectomy, we must make advancements in tech-
EMLA cream and anesthetic buffering. These tech-
nique so that vasectomy is more used by couples who
niques showed higher pain scores. EMLA cream
have completed childbearing or do not want chil-
combined with local anesthesia had an average VAS
dren. The development of the no-scalpel technique
pain score during vasectomy of 2.211 vs 0.6 for the
shows that improvements in technique and social
mini-needle and a VDS score of 0.612 vs 0.4 for the
marketing can dramatically increase the selection of
mini-needle. Buffered anesthesia had an average
anesthetic VAS pain score of 1.7 vs 1.5 for the mini-
propose a method that may make vasectomy a more
needle and an average VAS vasectomy pain score of
acceptable option by using a smaller gauge needle
while minimizing the equipment needed to perform
improved pain scores achieved by the mini-needle
technique, no extra preparation is needed. EMLA
Overall our patients reported mild pain during
cream is applied to the scrotal skin 1 hour before the
anesthesia and virtually no pain during vasectomy.
Since this is a descriptive study without an inherent
Comparing our technique to the no-needle jet in-
comparison group, we performed a literature search
jector anesthesia, our VAS scores were similar to
using the key words vasectomy and anesthesia in
those in the study by Weiss and Li that was done in
MEDLINE® in July 2009 to provide some comparison
for our results. From 197 titles and abstracts we iden-
pain score during anesthesia with the 30 gauge nee-
tified 10 articles providing pain scores associated with
dle was 1.5 vs 1.7 for the jet injector anesthetic.
Average pain score during vasectomy with the 30
additional article was found in the personal database
gauge needle was 0.6 vs 0.7 for the jet injector an-
esthetic. In the single group, randomized trial by
When comparing the mini-needle technique with
White and Maatman the average pain score during
the traditional vasal block, our pain scores are
anesthesia with the jet injector was 1.6, similar to
our results, but during vasectomy it was higher at
In the study by Aggarwal et al average pain
This website was updated with mini-needle
scores during anesthesia and procedure were higher
information in the interim between the 2 study re-
cruitment periods. The website describes the mini-
These data show that the jet injector is an appro-
needle technique and states that vasectomy will be
priate option for vasectomy anesthesia. Known as
without pain and most men describe vasectomy as
the no-needle technique, it may have marketing ap-
less painful than going to the dentist. This state-
peal. However, it appears to have varying results
ment did not appear to influence any other pain
depending on provider. It may also not be suitable
for all settings. The estimated cost of a jet injector is
Surprisingly there was only a weak correlation
$56216 and the device requires regular maintenance
between expected pain and anesthesia pain scores
and inspection. These factors may restrict its use in
(r ϭ 0.18, p Ͻ0.001), and between expected pain and
low resource settings and at clinics with low vasec-
vasectomy pain scores (r ϭ 0.26, p ϭ 0.003). Never-
tomy volume. Based on our study results equivalent
theless, patients can be reassured that the average
or improved pain control could be achieved with the
pain of the procedure is less than expected.
This is a descriptive study of a modified technique
The mini-needle technique uses only 2 cc 2% lido-
for vasectomy anesthesia that warrants further in-
caine compared to the conventional vasal block,
vestigation. The next step includes a randomized,
controlled trial comparing pain control with the
cost of $0.10 to $0.20/cc lidocaine this has the possi-
mini-needle technique vs that of the standard vasal
bility for significant savings in settings with a large
block and/or jet injector technique.
number of vasectomies. The small anesthetic vol-ume infiltrated directly into the surgical site did not
CONCLUSIONS
alter performance of the standard NSV technique in
The 30 gauge mini-needle technique is a promising
any way. Minimizing the superficial wheal for the
alternative to the standard vasal block, as evidenced
standard vasal block is recommended to facilitate
by our low pain scores. This technique may improve
pain control during vasectomy and increase patient
To our knowledge this is the first study to evalu-
acceptability, given the smaller needle size. Since
ate expected pain before vasectomy. Men expected
the 30 gauge needle technique does not require extra
an average of “discomforting” pain. VAS results
equipment and it is done with a small volume of
were significantly higher in patients operated on in
anesthesia, it may be particularly suitable in low
2007 than in 2009 (3.4 vs 2.9). An explanation may
resource settings and may make vasectomy even
be the inclusion of a description of the mini-needle
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